In my 25 years as a GP with a special interest in women’s health, what we understand by the term perimenopause has changed a lot. Years ago we thought it was just the few months before periods stopped.
I have to thank Dr Olivia Ham, a GP and British Menopause Society (BMS) Menopause Specialist, whose BMS Education presentation on the perimenopause last year resulted in a eureka moment for me and has been a game-changer for my clinical consultations for perimenopause.
“I think I am starting the menopause, doctor, and want to have HRT.”
This is the opening line of many consultations with 45- to 50-year-old women we deal with as GPs. Let’s start by looking at some definitions.
Menopause is a retrospective diagnosis. A woman is said to be in menopause if it has been 12 months since her last period.
Postmenopause is the time of a woman’s life beyond 12 months after her last period.
The above two are quite easy therapeutically for a doctor. The patient no longer needs contraception and will benefit in the short, as well as long-term, from hormone replacement therapy or HRT: job done. These two scenarios are quite a straightforward part of my clinical work.
Perimenopause, on the other hand, in terms of diagnosis and treatment is more like trying to nail jelly to the wall.
Perimenopause describes the time from the first occurrence of any symptoms to one year after a woman’s last period.
The average age of a woman’s last period is 51 years. Average age of onset perimenopause is 45 years. Before 45 is defined as early perimenopause but can occur. Before the age of 40 is defined as Premature Ovarian Failure, a topic for a future article.
While the median duration of perimenopause for women is four years, it might be a bit daunting for readers to learn that it can go on for as long as eight to 10 years.
What I find has improved in the last five to eight years of my practice is that women have now heard of the perimenopause and go to see their doctor. They just don’t know what perimenopasue means. Bottom line: what the woman in her 40s in front of me wants to know is ‘Am I going mad or is it my hormones?’
It is very important that my patient understands the gubbins of what is going on in her body through the perimenopasue. To that end I will do my best here to run through the workings of a ‘normal’ ovulatory cycle or a cycle during which an egg is released.
Ladies, essentially, we run a complicated hormonal balancing machine. It is a feedback system between the pituitary gland, the hypothalamus, both located in the brain, and the ovaries.
The hypothalamus releases FSH, follicle stimulating hormone; the pituitary gland, LH, leutinising hormone – both of these act on the ovary to facilitate ovulation.
The ovaries are our main source of oestrogen. Oestrogen is our dominant female hormone and is responsible for the changes of puberty but also has widespread effects on muscles, bones, brain, breasts, heart, blood vessels, as well as our pelvic organs, external genetalia and bladder. After a woman menstruates, during the first half of a regular, ovulatory cycle, oestrogen levels slowly rise to a peak. This results in release of LH, which then triggers ovulation. This usually occurs mid-cycle or midway between two periods. In the second half of the cycle, oestrogen levels drop and our progestogen hormone level rises. This is our premenstrual hormone and is responsible for symptoms we get in the premenstrual week.
What is going on during the perimenopause is not dissimilar to what happens to our motor after 200,000 miles: the complicated hormone balancing machine stalls, backfires, splutters and does not run in the smooth cyclical fashion described above.
What starts to happen is that some months we ovulate, some months we don’t. This has a kick-back effect on all of the female hormones in our hormonal axes.
This means that from 45 to 55 years of age, at different times, and in a completely random way, a woman’s oestrogen, progestogen and FSH and LH are up, down, sideways, too high, too low: pretty much all over the place. Which is exactly what I have heard my patients say a hundred times: “Dr, I feel like I am all over the place!” before bursting into tears.
Change to periods. Periods can slowly start to get further apart but more often simply become erratic and unpredictable. Periods can also become longer and heavier, sometimes flooding.
Hot flushes. Oestrogen impacts whole body temperature regulation, as heat production and dissipation relies on oestrogen receptors in the hypothalamus in the brain and elsewhere in the body.
Palpitations are a common complaint, more so than in menopause or post menopause.
Changes to body composition: women notice that it is much more difficult to lose weight than in their 30s and specifically weight gathers around the belly area.
Headaches are common and some women present with migraines for the first time.
Joint and muscle pains.
Sleep: 40 per cent of women in the perimenopause have sleep disturbance.
Fatigue is a common complaint.
Most debilitating are the mood and cognitive changes: 69 per cent of women in the perimenopause will experience mood changes; irritability, often anxiety, tearfulness and low mood. Women aged 45 to 55 have the highest suicide rate among women.
Poor concentration, poor memory, brain fog.
Seventy per cent of women in perimenopause will experience Genitourinary Syndrome of Menopause or GSM. GSM is the term given to vulval, vaginal and urinary symptoms.
Oestrogen deprivation and fluctuating oestrogen levels affect the tissue in the genital area including the urethra, or wee pipe, which exits at the top of the vaginal opening.
GSM symptoms are: atrophy, sometimes shrinkage of tissue in the vulval area, vaginal dryness, soreness and discomfort at times, accompanied by irritation and vaginal discharge. Urinary symptoms are common with burning when passing urine, as well as frequency or passing urine very often. Not surprisingly, GSM can result in low libido and decline in sexual wellbeing, often affecting relationships.
Unfortunately GSM symptoms go under-reported. I find in my practice that they are rarely volunteered, instead I have to specifically ask about them.
Now, any of you that read my article on Menopause last month will probably think; is this not the same list of symptoms as for menopause?
Yes, but what is going on hormonally in a woman’s body during perimenopause is completely different to what happens in the menopause state:
Perimenopause equals hormones all over the place and intermittently ovulating versus consistently low levels of oestrogen with persistently high FSH diagnostic of menopause state and no ovulation.
Understanding that is key to explaining to my patient the logic of the treatment approach, which is to switch off her current chaotic cycle and give her nice, calm steady hormone levels.
To achieve this we use contraception medication but in a slightly different way. If there are no contraindications, the combined oral contraceptive (COC), is prescribed, what many know as the normal pill. This is safe to use up to the age of 50.
COC contains oestrogen and progestogen and works by suppressing ovulation, which prevents the hormonal swings causing her symptoms. COC for perimenopause is taken without a break to achieve steady hormone levels. Where COC is contraindicated, a progestogen-only contraceptive can be equally effective. These come in the form of pill, injection, implant or intrauterine device or coil called Mirena coil. These can be safely used up to the age of 55 years. When GSM symptoms are prominent, I will also prescribe vaginal oestrogen therapy. This usually results in complete resolution of all GSM symptoms within one to four weeks .
If symptoms are inadequately controlled on the contraception treatment alone, top-up oestrogen therapy can be added in as a patch or gel.
A scenario that I have often encountered is my 46-year-old patient who presents with all of the above perimenopause symptoms, adamant that she has looked it all up, watched the Davina McCall TV programme, and demands to have HRT. The reality is that HRT alone will not treat her symptoms, for three reasons.
Firstly, it will not stop her getting pregnant, which is a real possibility right up to age 49 and less commonly beyond: HRT does not work as a contraceptive.
Secondly, HRT in the perimenopause can actually make her bleeding pattern worse. A woman still having periods requires cyclical HRT, which will give her a HRT bleed. This will superimpose a HRT cycle on top of her own erratic cycle and she could end up bleeding several times per month.
Thirdly, HRT will not suppress the woman’s own hormone cycle, which is what will eradicate her own hormonal fluctuations, which is causing her perimenopasue symptoms; only a contraceptive-type medication can do that.
My take-home message is that any woman age 45 or more who is having any of the above symptoms needs support and an offer of treatment and she should start off by going to see your GP.
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